Harvard sweetens reward for doctors who teach

3 hospitals agree to double budget

By Liz Kowalczyk, Globe Staff | March 9, 2007

Harvard Medical School will increase by millions of dollars a year its payments to doctors for teaching students, a recognition of how difficult it has become to persuade busy physicians to devote time to educating the next generation of care givers.

The medical school, Harvard University, and three major Harvard teaching hospitals -- Massachusetts General, Brigham and Women's, and Beth Israel Deaconess -- have agreed to double the funds for hospital-based instructors from $8 million to $16 million a year starting July 1.

There is wide variation in what theroughly 7,000 full-time instructors at Harvard Medical School are paid to teach the school's 771 students in classrooms, labs, and hospitals. Some are paid at well below going rates for doctors' services -- $30 an hour for some courses -- and many who provide on-the-job teaching at the hospitals are not paid at all. Under the new plan, the goal is to pay doctors $100 an hour to teach.

The amount is comparable to the hourly rate that a typical primary care doctor earns, though far less than what some surgeons and other specialists make.

Medical school faculty are required to teach or volunteer on committees 50 hours a year, but Harvard does not track how many hours doctors teach and does not actively enforce the policy.

The agreement comes as the medical school implements significant changes to its curriculum that will require even more intensive teaching by the faculty.

"The pressures of clinical practice make it harder for faculty to free up their time for teaching," said Cynthia Walker, executive dean for administration at the medical school. "Now it will be easier for them."

All the medical school's courses and hospital rotations have teachers, Walker said, but other faculty said course directors spend too much time trying to recruit teachers, andmore doctors are saying no to requests. In some cases, residents or fellows, who are junior doctors still in training,or even faculty from other universities, have been enlisted to teach.

"It's the single biggest problem facing virtually every course director," said David Cardozo, a neurobiology professor who headed a medical school task force created to study the problem. "In order to get faculty to teach, you have to offer sufficient financial compensation. It's very significant that this change is happening."

Cardozo is course director for the study of the human nervous system that students take during their second year. As in most Harvard Medical School courses, the students are divided into small groups of six to 10, requiring about 50 teachers. In addition to Harvard faculty,Cardozo uses residents and fellows, a neuroanatomist from the University of Massachusetts Medical School, and neurologists in private practice to teach his students. Because many residents and fellows are training at Harvard temporarily, there is a high turnover rate. The job pays $1,500 for 48 hours of work over eight weeks--about $30 an hour.

"It's almost embarrassing for course directors to tell tutors and lab instructors what it pays," Cardozo said.

The task force was appointed three years ago by the medical school's dean, Dr. Joseph Martin, who was frustrated that more doctors were not willing to teach. Based on its findings, a committee headed by Walker and Peter Slavin, the president of Mass. General, developed the plan for higher payments.Another committee will recommend how to give doctors more credit for teaching when considering promotions.

Medical schools across the country have struggled with this issue. As fees from insurers and government medicalprograms have stagnated and patient demand has grown, academic medical centers have pressured doctors to squeeze more appointments into the day.And doctors themselves have wanted to see more patients to boost their incomes,leaving them less time to teach. Many doctors also have felt compelled to spend more time on research,as grants and promotions have become more competitive.

"If a doctor is spending three hours with a group of third-year medical students, that's three hours not in an ambulatory clinic generating income or in the lab doing research," said Dr. Michael Epstein, chief operating officer at Beth Israel Deaconess Medical Center.

At the same time, hospitals are discharging patients faster, often after just a few days,giving medical students little time to understand what led to surgery or how to manage follow-up care, and making their interactions with senior physicians all the more crucial.

"Virtually every medical school is facing this problem," said Dr. Darrell G. Kirch, president of the Association of American Medical Colleges. "Historically they have all relied on the volunteer efforts of physicians to do teaching in the clinical setting. In the current economic climate, that model is breaking down."

He said the problem has contributed to the rise in medical school tuition, as medical schools try to raise money in order to pay doctors more. Some schools have undertaken philanthropic campaigns, while others have significantly expanded their faculties.

Harvard has a particular interest in attracting more doctors to teach, as it embarks on the most dramatic changes to its curriculum in 20 years, including requiring third-year students to spend the year in one hospital, following some of the same patients and developing longer-term relationships with faculty. Traditionally, third-year students have rotated from hospital to hospital. Medical students spend most of their last two years in hospitals, observing doctors, performing basic medical tasks, and discussing cases with physicians.

The unusual relationship between Harvard Medical School and its 18 affiliated teaching hospitals and research institutes makes the teaching crunch more challenging in Boston. Many medical schools have closer ties to their teaching hospitals, some even owning them and paying part of doctors' salaries.

But Harvard's teaching hospitals function independently. The physicians get salaries from the hospitals or earn their pay in private practice. The medical school operates on what is essentially a good-will system. In return for the Harvard seal on their stationery and the name on their résumés, faculty are supposed to teach or do committee work.

Mass. General, the Brigham, and Beth Israel Deaconess each will contribute about $1 million for the higher payments. The remaining roughly $13 million comes from Harvard University and Harvard Medical School. Walker said the medical school will talk with the other affiliated hospitals about contributing to the effort.

Slavin said he hopes the new pay system will enable physicians to spend more time with students.